Intensive Community Based Treatment for Children and Adolescents (ICBAT)

Mobile Crisis Intervention

We already provide coverage for Community Based Acute Treatment for Children and Adolescents (CBAT), Intensive Community Based Treatment for Children and Adolescents (ICBAT), and Mobile Crisis Intervention. We refer to CBAT and ICBAT as Acute Residential Treatment or Subacute Care.

Effective July 1, 2020, coverage will include medically necessary Family Support and Training as well as Therapeutic Mentoring.

For questions about your health coverage, claims, and benefits, call the Member Service number on the front of your ID card.

Expanded Coverage for Fluoride Supplements

Bright Futures, led by the American Academy of Pediatrics, has revised its recommendations for fluoride supplements to prevent dental cavities in children. As a result, effective January 1, 2019, as a one-day change, we’re updating our commercial medical plan coverage to reflect these changes, ensuring compliance with Preventive Services under the Affordable Care Act (ACA).

Our new coverage expands the age range to six months through 16 years of age. This benefit will be available at a $0 cost share for fully insured and self-insured non-grandfathered plans, as well as grandfathered accounts that adopted the ACA’s Preventive Services benefits. Coverage is subject to other health plan network requirements and provisions.

Help for Members Affected by California Wildfires

As deadly wildfires continue to burn in California, Blue Cross Blue Shield is committed to providing support to all of our members who live in affected areas. To expedite access to care, we’re adjusting the following policies for members in impacted areas, including:

Allowing early refills of prescription medications

Waiving referral, authorization and pre-certification requirements for medical and pharmacy services in areas that have been declared federal disaster zones

Offering medical and behavioral health visits through Well Connection at no cost, with no copayments and no deductibles

Questions or Concerns?
You can call Member Service at the number on your ID card or 1-800-262-2583. You can also call our 24/7 Nurse Care Line at 1-888-247-2583 to talk to a registered nurse.

Help for Members Affected by Hurricane Michael

Blue Cross Blue Shield of Massachusetts is saddened by the impact of Hurricane Michael. We’re committed to providing support to all members who live in affected areas of Florida. To help expedite access to care, we’re adjusting the following policies for members in impacted areas, including:

Allowing early refills of prescription medications

Waiving referral, authorization and pre-certification requirements for medical and pharmacy services in areas that have been declared federal disaster zones

Questions or Concerns?
You can call Member Service at the number on your ID card or 1-800-262-2583. You can also call our 24/7 Nurse Care Line at 1-888-247-2583 to talk to a registered nurse.

Prior Authorization Request Required for Genetic Testing

Beginning January 1, 2019, your doctor will need to request prior authorization from us before we cover the cost of certain genetic tests.

What Are Genetic Tests?
These tests can help identify medical risks that run in your family or find any DNA changes related to a specific disease. If a doctor requests these procedures for you, he or she may also suggest genetic counseling to help you better understand the test results.

The following genetic tests will require prior authorization:

DNA testing of hereditary heart disease risks

DNA testing of hereditary cancer risks

Testing to detect changes in DNA which may indicate a specific disease or condition

What Is Prior Authorization?
The prior authorization process ensures you receive health care services that are medically necessary for you and covered by your health plan.

Questions?
If you have any questions, call the Member Service number on the front of your ID card.

New Contraceptives Mandate in Massachusetts

On Monday November 20, 2017, Governor Baker signed into law the Advancing Contraceptive Coverage and Economic Security in our State (ACCESS) bill. It is scheduled to go into effect on May 20, 2018, and will now require coverage with no cost share for the following contraceptive methods and services for women:

Follow-up services related to the drugs, devices, products and procedures

Dispensing Requirement

By State law, contraceptives can be dispensed for an initial fill for a 3-month period and then, a 12-month period. A prescription may be dispensed all at once, or over the course of the 12-month period, regardless of coverage.

Who Does This Impact?

As a Blue Cross Blue Shield of Massachusetts member, contraceptives are already covered, so you will experience no disruption to your plan or coverage.

Questions? Contact Member Service using the number on your ID card for help with any questions related to your health plan.

You're Getting Access to More Dentists

Beginning January 1, 2018, Dental Blue® members will be able to get service from nearly 122,000 dentists, and 300,000 provider locations across the country through our Dental Blue National Network. This new network is one of the largest in the country, and is nearly twice the size of our current national network. To reflect this change, you'll receive a new member ID card in November. In addition, we've updated our online Find a Doctor & Estimate Costs tool to include zip code and plan type searches, making it easier for you to find nearby dentists and locations. You also won't have to conduct separate searches for dentists outside Massachusetts.

Support for Our Members Impacted by Recent Hurricanes

Blue Cross Blue Shield of Massachusetts is saddened by the impact of Hurricane Irma. We're committed to providing support to all our members who live in affected areas of Florida and Puerto Rico. To help expedite access to care, we're adjusting the following policies for members in impacted areas:*

Processing claims for services rendered by out-of-network providers at the member's in-network level of benefits

If Members Have Questions or Concerns

Members can call Member Service at the number on their ID cards or 1-800-262-2583. They can also call our Blue Care® Line at 1-888-247-2583 to talk to a registered nurse.

If you have questions, please contact your account executive.

*The adjusted policies will be in place for four weeks and reevaluated as necessary.

Enhancements to Imaging and Sleep Management Programs

We are improving how we manage our imaging and sleep services, increasing the quality and efficiency of both services for members and employers. On June 1 2017, we'll now require prior authorization for all imaging and sleep services included in our management programs. AIM Specialty Health (AIM) will manage authorizations. AIM has experience managing imaging and sleep services for our HMO members, as well as for most other Blue plans with approximately 42 million lives under management across the country.

For our HMO members

The imaging management program, which has been in place since 2005, will move to a full Utilization Management (UM) program for procedures that require a pre-service prior authorization. A UM program requires a Medical Necessity determination prior to the coverage of services. We'll continue to exclude certain provider groups in Massachusetts from the management process when those groups meet established criteria.

Your sleep management program, which has been in place since 2013, already requires authorization before the service, and so is unchanged. All provider groups in Massachusetts participate in this process.

For our PPO members

New requirements for pre-service authorization will go into effect for in-state and out-of-state services. As a result of this change, if out-of-state PPO members don't obtain pre-service authorization, they'll be financially responsible for the cost of services. As with our HMO programs, some Massachusetts provider groups may be excluded from the management requirements for imaging, and all provider groups are required to participate in the sleep management program.

Learn More

To learn more about these enhancements and how they impact you, please review our fact sheet here.

Questions?

If you have any questions, please contact Member Service using the number on the front of your Member ID card.

Coverage for 3D Mammograms Begins in 2017

Regular screenings are the best way to find breast cancer at an early stage, when treating the disease has the highest success rates. Blue Cross Blue Shield of Massachusetts suggests that members talk to their doctor about the benefits and timing of mammogram screenings for their age and health history. In addition to coverage for standard mammography screenings, on January 1, 2017, we'll begin providing coverage for 3D mammograms (digital breast tomosynthesis), subject to the same guidelines as standard mammograms.

As a result of favorable improvements in the following hospitals' cost or quality performance, we are updating their tier in our Blue Options v.5 benefit designs and Hospital Choice Cost Sharing benefit designs. This one-day change is effective for all plans and accounts on January 1, 2017. With this update, members will have lower out-of-pocket costs when receiving services at these hospitals.

Blue Options v.5

Hospital

Previous Blue Options Tier

New Blue Options Tier

Reason for Tier Improvement

Sturdy Memorial Hospital

Basic Benefits Tier

Standard Benefits Tier

Met moderate cost benchmark

Nashoba Valley Medical Center

Standard Benefits Tier

Enhanced Benefits Tier

Met quality benchmark

Previous Blue Options Tier

Sturdy Memorial Hospital

Basic Benefits Tier

Nashoba Valley Medical Center

Standard Benefits Tier

New Blue options Tier

Sturdy Memorial Hospital

Standard Benefits Tier

Nashoba Valley Medical Center

Enhanced Benefits Tier

Reason for Tier Improvement

Sturdy Memorial Hospital

Met moderate cost benchmark

Nashoba Valley Medical Center

Met quality benchmark

Hospital Choice Cost Sharing

Hospital

Previous HCCS Cost Share

New HCCS Cost Share

Reason for Tier Improvement

Sturdy Memorial Hospital

Higher Cost Share

Lower Cost Share

Met moderate cost benchmark

Previous HCCS Cost Share

Sturdy Memorial Hospital

Higher Cost Share

New HCCS Cost Share

Sturdy Memorial Hospital

Lower Cost Share

Reason for Tier Improvement

Safely Dispose of Expired or Unwanted Drugs on October 22, 2016

Medications don't last forever. Over time, their chemical properties change, making them less effectiveâeven dangerous. The U.S. Drug Enforcement Administration's next National Prescription Drug Take Back Day is on Saturday, October 22, 2016, from 10:00 a.m. to 2:00 p.m.

Now is a great time to go through your medicine cabinet and check the expiration dates on your medicationsâeverything from aspirin to prescription drugs. Take all those expired medications and bring them to your local disposal location. To find Take Back locations in your area, please use the U.S. Drug Enforcement Administration's search tool.

Blue Options and Hospital Choice Cost Sharing

Update on Provider Tiers

As of January 1, 2016, we will update the hospital and primary care provider tiers for our Blue Options and Hospital Choice Cost Sharing (HCCS) plans.

Why We Are Updating our Tiers

In order to maintain the affordability of our tiered network plans, we periodically review and update our tiers based on the most current provider data. This process encourages the hospitals and doctors in our networks to continue to improve their cost and quality performance.

We analyze our tiers based on standard performance measurement principles accepted by local and national physician leaders and measurement experts. This is our fifth update to our tiered network plans.

How the Update Affects You

The tier update will change the costs for care received from some doctors and hospitals. Your costs may go up or down, depending on whether a tier is changed for any of your doctors or hospitals.

If you are a Blue Options member, the tier changes will go into effect when your plan is renewed. If your plan includes Hospital Choice Cost Sharing, the tier changes will go into effect for all members on January 1, 2016. The tier update will be identified on member ID cards and in our provider directory as Blue Options v.5.

As of January 1, 2016, members of our HMO Blue New England Options plans will have access to tiered providers in New Hampshire.This change will be effective when your plan renews. The plans include:

HMO Blue New England Options

HMO Blue New England Options Deductible

HMO Blue New England Options Deductible II

HMO Blue New England Options Deductible III

Members in these plans already have access to participating providers from six networks within the New England states. These members will continue to have access to the same network of providers as they do today in New England.

However, New Hampshire doctors and hospitals will now be placed into one of two benefit tiers. Member costs for care from some doctors and hospitals in New Hampshire will change, depending on the new tier a doctor or hospital is in.

A network Primary Care Provider or network hospital in NH will now be either:

A Tier 1 (Enhanced Benefit Tier) provider

A Tier 2 (Standard Benefits Tier) provider

Network doctors and general hospitals in the New England network located outside of Massachusetts or New Hampshire will continue to be in the Enhanced Benefits Tier.

For New England plans with the Hospital Choice Cost Sharing feature, there is no change to the member's cost share. All New Hampshire hospitals are considered "Lower Cost Share".

Get ready for our newly improved Find a Doctor and Estimate Costs tool!

Providing you with simple and actionable information regarding provider health care cost and quality is an important ingredient in helping you take control of your health care. Later this year, we'll unveil our newly redesigned Find a Doctor and Estimate Costs tool, giving you a better user experience. Soon you will be able to:

Conduct intuitive searches making it easier to find what you need, when you need it

We have decided to expand access to Xgeva and Prolia (Denosumab) to allow our members in Massachusetts to receive this medical or pharmacy benefits. This change will take place on October 1, 2015.

Currently, to save overall costs on these medications, you can only get the medication through a network specialty pharmacy or from a home infusion therapy provider. We'll be able to expand access in Massachusetts and still maintain the cost savings achieved by making a benefit change.

Questions?

If you have any questions, please contact us at the number on the front of your Blue Cross Blue Shield of Massachusetts ID card.

Important Changes to Covered Medications

We previously communicated that this change would be effective July 1, 2015. Please be advised that this change will now be effective on October 1, 2015.

Effective October 1, 2015, coverage is changing for the medications listed in the table below.

If your pharmacy benefits are administered by another pharmacy benefits manager, we encourage you to discuss this change with them and how the medications will be covered.

You should always talk to your doctor about available alternatives for getting your medication. Here are some options:

Get the medication from a retail pharmacy within our specialty network. A medication copay, deductible and/or co-insurance would apply, and the doctor will need to request prior authorization. The medication can be shipped to the doctor's office or outpatient hospital clinic for administration. In these instances, an office visit copay, deductible, and/or co-insurance applies.

Obtain medication through a home infusion therapy provider. If medically appropriate, you can have medication administered by a home infusion therapy provider. To determine if this is the best option for you, consult with your doctor. Your doctor can refer you to a network home infusion therapy provider who can provide and administer the medication either in your home or another convenient setting depending on your specific health care benefits. Prior authorization is required.

If you currently receive medication from a home infusion therapy provider or dialysis facility, there is no change in your coverage. We will be notifying impacted members by September 1, 2015.

Certain in-state physicians and hospitals will continue to be allowed to administer these medications in the doctor's office or outpatient hospital clinic. Additional information will be shared as it is available.

Medication Name

Medication Class

IVIG

Immune Serum

Remicade

TNF inhibitor

Botulinumtoxin

Neuromuscular Blocker

Medication Class

IVIG

Immune Serum

Remicade

TNF inhibitor

Botulinumtoxin

Neuromuscular Blocker

Questions?

If you have any questions, please contact us at the number on the front of your Blue Cross Blue Shield of Massachusetts ID card.

New Authorization Requirements for HMO and Blue Choice Plans

Starting July 1, 2015, we will require prior authorization for certain drugs when administered in a doctor's office, by a home health care provider, or in outpatient hospital and dialysis settings. This change does not affect these medications in inpatient, surgical day care, urgent care centers, and ER settings. This change applies to HMO and in-network Blue Choice plans. We encourage you to discuss this change with your health care provider if you take a medication that will require prior authorization. If you are affected by this change, we will be notify you by June 1, 2015.

For a list of medications that require prior authorization, please visit www.bluecrossma.com/pharmacy and select Pharmacy Management Program and then Prior Authorization.

Pharmacy Update: Flonase and Fluticasone No Longer Covered

Due to the over-the-counter availability of the intranasal corticosteroid medication Flonase, we will no longer cover it or its generic version, flucticasone, our pharmacy benefit. This change will go into effect on April 15, 2015. We will be sending letters to impacted members to notify them of the change.

Formulary exceptions, including those previously approved, will no longer be available after April 15, 2015. This change applies to most commercial plans including, but not limited to, group Medex®' with pharmacy benefits and Managed Blue for SeniorsSM.

Coming in 2015: Updates to Our Pharmacy Formulary Program

On January 1, 2015, we will be updating our formulary program. We want to make you aware of these changes now so you can plan. We have already advised prescribers of the changes. Members who are directly affected will be notified directly on or before December 1, 2014.

We will be changing the coverage tier on some medications, adding dosing limits to others, and removing some medications from our formulary drug list. We've highlighted the changes below. Rest assured, members and prescribers will continue to have access to a variety of safe and effective medications at affordable prices.

Two Types of Plans Will Be Affected:

Commercial medical plans with pharmacy benefits

Medex®' plans with the three-tier pharmacy benefit

Medications That Will No Longer Be Covered

After carefully reviewing each drug's cost and covered alternatives, the medications in the chart below will no longer be covered. However, when medically necessary, your doctor or the person who prescribed the drug may request an exception to have these medications covered.

We previously communicated that ophthalmic prostaglandins (for glaucoma) including Lumigan, Travatan Z, Travatan, and Xalatan would no longer be covered as of 1/1/15. These medications will continue to be covered for our members in accordance with our Step Therapy program and there will be no change in coverage for members currently taking these medications.

Drug Class

Non-Covered Medication or Supply

Insulin â basal

Levemir

Topical testosterone

Testim, Testosterone AG

Ophthalmic anti-inflammatory

Vexol, FML Forte

Ophthalmic antibiotics

Moxeza, Vigamox, Zymar

Growth Hormone

Somavert

Sedative hypnotics (sleep aids)

Lunesta, Sonata

Antidepressants

Cymbalta, Lexapro

Compounded medications

Bulk chemical ingredients when used as part of a compounded medication

Non-Covered Medication or Supply

Insulin â basal

Levemir

Topical testosterone

Testim, Testosterone AG

Ophthalmic anti-inflammatory

Vexol, FML Forte

Ophthalmic antibiotics

Moxeza, Vigamox, Zymar

Growth Hormone

Somavert

Sedative hypnotics (sleep aids)

Lunesta, Sonata

Antidepressants

Cymbalta, Lexapro

Compounded medications

Bulk chemical ingredients when used as part of a compounded medication

Medication with New Quality Care Dosing Limit

To ensure the quantity and dose of medication a member receives meets Federal Drug Administration, manufacturer, and clinical recommendations, we are adding a Quality Care Dosing limit to the following medications:

Medication Name

Dosage

Quality Care Dosing Limit

Insulin vials

All strengths

4 vials per prescription

Insulin pens/cartridges

All strengths

15 pens/cartridges per prescription

Dosage

Insulin vials

All strengths

Insulin pens/cartridges

All strengths

Quality Care Dosing Limit

Insulin vials

4 vials per prescription

Insulin pens/cartridges

15 pens/cartridges per prescription

Medications That Will Be a Benefit Exclusion as It Is Now Available Over-the-Counter

The following medication will be excluded from our pharmacy coverage. We are making this change due to the over-the-counter availability of this medication, which can be purchased without a prescription. This change will apply to all commercial plans, group Medex®' plans with pharmacy benefits, and Managed Blue for Seniors.

Drug Class

Medication Name

Proton pump inhibitors

Nexium capsules (20mg strength only)

Medication Name

Proton pump inhibitors

Nexium capsules (20mg strength only)

Medications That Will No Longer Be Available Through the Express Scripts Mail Service PharmacySM

The following medications will be covered only when purchased from a retail pharmacy in our network.

Medication Name

Pharmacy update: Nasacort AQ no longer covered

Due to the over-the-counter availability of the anti-inflammatory allergy medication Nasacort AQ, we will no longer cover it in our pharmacy benefit. This change goes into effect August 1, 2014.

Formulary exceptions, including those previously approved, will no longer be available. This change applies to most commercial plans, group Medex®' with pharmacy benefits, and Managed Blue for SeniorsSM.

Important Change to Your Prescription Drug Coverage

Currently, you can fill a 90-day supply of certain prescription medications at a retail pharmacy, but only pay the cost for a 30-day supply. Beginning August 1, 2014, when you fill a 90-day prescription at a retail pharmacy, you must pay three times the cost of a 30-day supply. For example, if you pay a $25 copayment today, you'll pay a $75 copayment starting August 1, 2014.

These medications include:

Estring

Femring

If this change affects you* and you have questions about your treatment options, such as whether a less expensive medication is available, please talk to your doctor.

You may be eligible for cost savings through the mail service pharmacy, Express Scripts PharmacySM. You can log on to the Express Scripts mail pharmacy site at www.StartHomeDelivery.com, and follow the prompts, or call Express Scripts at 1-877-697-7088, 8:30 a.m. to 6:00 p.m. ET, and a representative will help you get started.

Osteoarthritis injections: coverage change

Effective July 1, 2014, the following medications will not be covered for select plans with pharmacy benefits and for Medex® plans with pharmacy benefits. If you are impacted by this change, you will also get a letter with more details.

Orthovisc

Synvisc

Synvisc-One

How we came to this decision:

We reviewed new evidence-based guidelines on treatment of osteoarthritis of the knee, including guidance from the American Academy of Orthopaedic Surgeons and the Blue Cross Blue Shield Association's Technology Evaluation Center.

New Changes at www.express-scripts.com

Express Scripts, has updated its website. Enhancements include new self-service capabilities, which help make prescription management faster and easier.

Specialty Pharmacy Name Change

On January 1, 2014, CuraScript®, a subsidiary of Express Script®, will join Accredo Health Group, Inc.® You can use the Accredo website and telephone number listed below for questions related to a specialty medication. This change will not interrupt or delay future refills, as only the name of the pharmacy is changing.

Accredo Health Group, Inc.
1-877-988-0058
www.accredo.com

Changes to select medications when administered in a doctor's office or hospital1

Starting January 1, 2014, the following medications will no longer be covered through your medical benefit. They will only be covered if they are purchased prescription through your pharmacy benefits and administered by your physician. If you do not have pharmacy benefits, speak to your benefits manager to learn how to obtain prescription(s).

Drug Class

Medication Name

Hyaluronic Acids/Joint Fluid Replacement

Euflexxa, Synvisc-One, Synvisc, Orthovisc, Supartz, Hyalgan, Gel-One

Medication Name

Hyaluronic Acids/Joint Fluid Replacement

Euflexxa, Synvisc-One, Synvisc, Orthovisc, Supartz, Hyalgan, Gel-One

The following medications will no longer be covered when administered in a doctor's office or hospital setting. They will only be covered when purchased from a retail pharmacy in our specialty network. If you do not have pharmacy benefits, speak to your benefits manager to learn how to obtain prescription(s).

Drug Class

Medication Name

Fertility Regulator

Ovidrel2

Antipsoriatic

Stelara

Anti-TNF-alpha - Monoclonoal Antibodies

Simponi

Bone Density Regulators

Prolia, XGEVA

GGnRH/LHRH Antagonists

Cetrotide

Growth Hormone

Somavert

Receptor Antagonist

N/A

Interleukin-1 Blockers

Arcalyst

Interleukin-1beta Blockers

Ilaris

Multiple Sclerosis Agent

Extavia

Antineoplastic or Premalignant Lesion Agent - Topical

Panretin

Medication Name

Fertility Regulator

Ovidrel2

Antipsoriatic

Stelara

Anti-TNF-alpha - Monoclonoal Antibodies

Simponi

Bone Density Regulators

Prolia, XGEVA

GGnRH/LHRH Antagonists

Cetrotide

Growth Hormone

Somavert

Receptor Antagonist

N/A

Interleukin-1 Blockers

Arcalyst

Interleukin-1beta Blockers

Ilaris

Multiple Sclerosis Agent

Extavia

Antineoplastic or Premalignant Lesion Agent - Topical

Panretin

Over-the-Counter Medications

For non-grandfathered health plans under the Affordable Care Act, the following list includes over-the-counter medications that are covered with no cost share when they are prescribed for you by your doctor. This list is up to date as of January 1, 2014, and is subject to change at any time.

Generic aspirin (81mg) is covered for females age 59-79 and males age 45-79.

Generic folic acid is covered for females up to age 50.

Generic iron is covered for infants up to 12 months old.

Generic smoking-cessation drugs are covered for up to a 90-day supply per calendar year.

New "My Rx Choice" Program for Commercial Accounts with pharmacy benefits

Beginning January 1, 2014, Express Scripts will begin a promotional mailing campaign to encourage the use of mail service delivery. Members taking a medication that would be suitable for the mail service pharmacy will receive a letter to educate them on the benefits of and potential savings of the mail service pharmacy program. Please contact your Account Executive with any questions.

1These changes do not impact Medex®' plans with a three tier pharmacy benefit

2Purchase of this medication is only available when purchased through a network specialty fertility retail pharmacy.

Coming January 1, 2014: Updates to Pharmacy Formulary Program

With these changes, members and doctors will continue accessing a variety of safe, clinically effective medications at affordable prices.

Which Plans Will Be Affected?

Commercial plans with pharmacy benefits

Medex®' plans with the three-tier pharmacy benefit

Doctors and hospitals have already been advised of these changes. Members affected by any of these changes will be notified directly no later than December 1, 2013.

Medications Changing to Non-Covered Status

After careful consideration and cost evaluation of each drug's covered alternatives, the following medications will no longer be covered.

Drug Class

Non-Covered Medication or Supply

Insulins

Novolog, Novolin

Migraine Treatments

Alsuma, Relpax, Zomig/ZMT (members currently using these medications will not be required to obtain a formulary exception for coverage)

H. Pylori Treatments

Pylera, Helidac, PrevPac

Topical Steroids

Clobex

Hyaluronic Acids/Joint Fluid Replacement

Euflexxa, Hyalgan, Supartz

Glucose Testing Supplies-Testing Strips

Precision X-tra (members currently using this medication will not be required to obtain a formulary exception for coverage and will be covered at Tier 3)

Non-Covered Medication or Supply

Insulins

Novolog, Novolin

Migraine Treatments

Alsuma, Relpax, Zomig/ZMT (members currently using these medications will not be required to obtain a formulary exception for coverage)

H. Pylori Treatments

Pylera, Helidac, PrevPac

Topical Steroids

Clobex

Hyaluronic Acids/Joint Fluid Replacement

Euflexxa, Hyalgan, Supartz

Glucose Testing Supplies-Testing Strips

Precision X-tra (members currently using this medication will not be required to obtain a formulary exception for coverage and will be covered at Tier 3)

When medically necessary, a health care provider may request an exception to have these medications covered.

Medications Changing Tier Status

When we determine that a medication's clinical and financial value changes relative to alternative medications in its class, we change the medication's tier. Depending on the tier change, members may be required to pay more or less for these medications.

The medications below will change to the following tier levels:

Drug Class

Medication Name

Covered Tier Level as of January 1, 2014

Irritable Bowel Treatments

Amitiza

Tier 2

Hormone Replacement Therapy

Premarin

Tier 2

Women's contraceptives

Nuvaring, Ortho-Evra, Depo-Provera-150, Medroxyprogesterone

Tier 1

Medication Name

Irritable Bowel Treatments

Amitiza

Hormone Replacement Therapy/strong>

Premarin

Women's contraceptives

Nuvaring, Ortho-Evra, Depo-Provera-150, Medroxyprogesterone

Covered Tier Level as of January 1, 2014

Irritable Bowel Treatments

Tier 2

Hormone Replacement Therapy/strong>

Tier 2

Women's contraceptives

Tier 1

New Quality Care Dosing Limits

To monitor that the quantity and dose of medication that a member receives meets Federal Drug Administration, manufacturer, and clinical recommendations, we are adding the following Quality Care Dosing limits to the medication below:

Medication Name

Dosage

QCD limit

Epinephrine, Epi-pen, Auvi-Q

All Strengths

2 injections per prescription

Dosage

Epinephrine, Epi-pen, Auvi-Q

All Strengths

QCD limit

Epinephrine, Epi-pen, Auvi-Q

2 injections per prescription

Medications requiring Prior Authorization Effective January 1, 2014

The following medications will require a prior authorization

Drug Class

Medication Name

Compounded Medications

ketamine, gabapentin, diclofenac, ketoprofen, flurbiprofen, oral erectile dysfunction medications and oral pain/analgesic medications when included as part of a compounded medication

Weight Loss

Belviq

Medication Name

Compounded Medications

ketamine, gabapentin, diclofenac, ketoprofen, flurbiprofen, oral erectile dysfunction medications and oral pain/analgesic medications when included as part of a compounded medication

Weight Loss

Belviq

New Step Therapy Policy-Effective January 1,2014

Drug Class

Medication Name

Oral Medications for treatment of Prostate Cancer

Step 1: Zytiga
Step 2: Xtandi (members currently using this medication will not be required to obtain a prior authorization for coverage)

Medication Name

Oral Medications for treatment of Prostate Cancer

Step 1: Zytiga
Step 2: Xtandi (members currently using this medication will not be required to obtain a prior authorization for coverage)

Medications no longer covered when administered in a doctor's office or hospital setting*

The following medications will no longer be covered when administered in a doctor's office or hospital setting. They will only be covered if they are purchased through your pharmacy benefits.

Drug Class

Medication Name

Hyaluronic Acids/Joint Fluid Replacement

Euflexxa, Synvisc-One, Synvisc, Orthovisc, Supartz, Hyalgan, Gel-one

Medication Name

Hyaluronic Acids/Joint Fluid Replacement

Euflexxa, Synvisc-One, Synvisc, Orthovisc, Supartz, Hyalgan, Gel-one

Coverage will no longer be available for the following medications when administered in a doctor's office or hospital setting. Coverage will only be available when purchased from a retail pharmacy in our specialty network.

Drug Class

Medication Name

Fertility Regulator

Ovidrel

Antipsoriatic

Stelara

Anti-TNF-alpha - Monoclonoal Antibodies

Simponi

Bone Density Regulators

Prolia, Xgeva

GnRH/LHRH Antagonists

Cetrotide

Growth Hormone Receptor Antagonist

Somavert

Interleukin-1 Blockers

Arcalyst

Interleukin-1beta Blockers

Ilaris

Multiple Sclerosis Agent

Extavia

Antineoplastic or Premalignant Lesion Agent Topical

Panretin

Medication Name

Fertility Regulator

Ovidrel

Antipsoriatic

Stelara

Anti-TNF-alpha - Monoclonoal Antibodies

Simponi

Bone Density Regulators

Prolia, Xgeva

GnRH/LHRH Antagonists

Cetrotide

Growth Hormone Receptor Antagonist

Somavert

Interleukin-1 Blockers

Arcalyst

Interleukin-1beta Blockers

Ilaris

Multiple Sclerosis Agent

Extavia

Antineoplastic or Premalignant Lesion Agent Topical

Panretin

*These changes do not impact Medex plans with a three tier pharmacy benefit
Purchase of this medication is only available when purchased through a network specialty fertility retail pharmacy.

Changes to Your Pharmacy Benefits for 2014

Because you've chosen to be more involved in your health care, we want you to be aware of changes early so you can plan. In 2014, we will be updating our drug formulary to adjust how some medications are covered, and specify that certain specialty drugs be purchased at a network specialty pharmacy. As a Blue Cross member, you will continue to have access to a variety of effective medications at affordable prices. Changes will be made in:

Non-covered medication status (Some specialty drugs must now be purchased at a network specialty pharmacy, and will not be covered if administered in a doctor's office or outpatient facility.)

Coming January 1, 2013: Updates to Pharmacy Formulary Program

With these changes, members and doctors will continue accessing a variety of safe, clinically effective medications at affordable prices.

Which Plans Will Be Affected?

Commercial plans with pharmacy benefits

Medex® plans with the three-tier pharmacy benefit

Doctors and hospitals have already been advised of these changes. Members affected by any of these changes will be notified directly no later than December 1, 2012.

Medications Changing to Non-Covered Status-Effective January 1, 2013

After careful consideration and cost evaluation of each drug's covered alternatives, the following medications will no longer be covered.

Drug Class

Non-Covered Medication or Supply

HMG Cholesterol Inhibitors

Lipitor tablets (members currently using this medication will not be required to obtain a formulary exception for coverage)

Phosphate Binders

Phoslyra solution

Low Molecular Weight Heparins

Arixtra, Fragmin, Innohep, and Lovenox injections

Glaucoma

Clobex

Ophthalmic Antibiotic Combinations

Tobradex ST solution

Non-Covered Medication or Supply

HMG Cholesterol Inhibitors

Lipitor tablets (members currently using this medication will not be required to obtain a formulary exception for coverage)

Phosphate Binders

Phoslyra solution

Low Molecular Weight Heparins

Arixtra, Fragmin, Innohep, and Lovenox injections

Glaucoma

Clobex

Ophthalmic Antibiotic Combinations

Tobradex ST solution

When medically necessary, a health care provider may request an exception to have these medications covered.

Medications Changing Tier Status-Effective January 1, 2013

When we determine that a medication's clinical and financial value changes relative to alternative medications in its class, we change the medication's tier status. Depending on the indicated tier change, members may be required to pay more or less for these medications.

Covered Tier Level as of January 1, 2013

For members with the BlueValue Rx formulary, these supplies will be non-covered

Pegylated Interferons

Tier 3

The medication Rozerem (sedative hypnotic) will become a Tier 3 covered medication and members will no longer require a formulary exception for coverage to be provided.

New Quality Care Dosing (QCD) Limits-Effective January 1, 2013

To monitor that the quantity and dose of medication that a member receives meets Federal Drug Administration (FDA), manufacturer, and clinical recommendations, we are adding the following Quality Care Dosing limits to the medications listed:

Medication

Dosage

QCD limit

Lidoderm (lidocaine) patch

5%

90 patches per prescription

Dosage

Lidoderm (lidocaine) patch

5%

QCD limit

Lidoderm (lidocaine) patch

90 patches per prescription

Prior Authorization for Medications Administered Using the Medical Benefit-Effective January 1, 2013

For members enrolled in our HMO, POS, and Access Blue plans, prior authorization is required under members' medical benefits for certain medications that are administered in a doctor's office, hospital outpatient setting, or by a home infusion therapy provider. This requirement will also apply to the following medications.

Alphanine®' SD

Bebulin VH

Benefix®

Corifact®

Eylea®

Gammaked®

Gamunex®

Lucentis®

Macugen®

Omnontys®

Pegasys® proclick

Regranex®

Wilate®

Xiaflex®

The prior authorization requirements may already apply when members fill their prescriptions at retail pharmacies.

Benefit Exclusions-Effective January 1, 2013

All drugs in the therapeutic class of ophthalmic solutions used to treat allergies will be excluded from our pharmacy benefit coverage. Formulary exceptions, including those previously approved, will no longer be available for this class of medications. This change will apply to all commercial plans, group MedexÂ® plans with pharmacy benefits, and Managed Blue for Seniors.

In addition, for group Medex plans with pharmacy and Managed Blue for Seniors, all drugs in the therapeutic class of non-sedating antihistamines will be excluded from our pharmacy benefit coverage effective January 1, 2013. This exclusion already exists within our commercial plans. Medications in this class include Allegra D, and Clarinex.

We are making these changes due to the over-the-counter availability of several products in these classes, which can be purchased without a prescription.